Provider Demographics
NPI:1417087594
Name:MAA, GOODMAN CHESTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:GOODMAN
Middle Name:CHESTER
Last Name:MAA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1578 EMERALD LN
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4043
Mailing Address - Country:US
Mailing Address - Phone:909-869-6678
Mailing Address - Fax:
Practice Address - Street 1:8654B ON THE MALL STE 154-B
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3232
Practice Address - Country:US
Practice Address - Phone:714-826-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice